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Sinus bradycardia: A regular but unusually slow heart beat (60 beats/minute or less at
rest). Sinus bradycardia can be the result of many things including good physical fitness,
medications, and some forms of heart block. "Sinus" refers to the sinus node, the heart's
natural pacemaker which creates the normal regular heartbeat. "Bradycardia" means that
the heart rate is slower than normal.

• Characteristics:
ECG Characteristics

• Rate: Less than 60 per minute.

• Rhythm: Regular.
• P waves: Upright, consistent, and normal in morphology and duration.
• P-R Interval: Between 0.12-0.20 seconds in duration.
• QRS Complex: Less than 0.12 seconds in width, and consistent in morphology.

• Causes:
Bradycardia may be physiological as in

i. Athletes
ii. Young people
iii. Sleeping patients

· Pathologic causes include

i. Hypothyroidism
ii. Drugs
a. Beta blockers
b. Calcium channel blockers
c. Digoxin
d. Lithium
e. Paclitaxel,
f. Toluene
g. Dimethyl sulfoxide
h. Topical ophthalmic acetylcholine,
i. Fentanyl
j. Alfentanil
k. Sufentanil
l. Reserpine
m. Clonidine
iii. AV block
iv. Inferior wall MI
v. Sick sinus syndrome
vi. Hypothermia
vii. Electrolyte disorders
viii. Raised intracranial pressure
ix. Vasomotor syncope
x. Infection
xi. Hypoglycemia
xii. Sleep apnea

• Management:
Prehospital Care
Intravenous access, supplemental oxygen, and cardiac monitoring should be initiated in the field.

In symptomatic patients, intravenous atropine may be used.

In rare cases, transcutaneous pacing may need to be initiated in the field.

Emergency Department Care

Care in the ED should first rapidly ensure the stability of the patient's condition. This is followed
by an investigation into the underlying cause of the bradycardia.

Patients in unstable condition may require immediate endotracheal intubation and transcutaneous
or transvenous pacing.

Patients should have continuous cardiac monitoring and intravenous access.

In hemodynamically stable patients, attention should be directed at the underlying cause of the

In sick sinus syndrome, drug therapy approaches have been relatively disappointing. While
atropine has aided some patients transiently, most patients ultimately require placement of a
pacemaker. Guidelines on permanent pacing are available from the American College of
Cardiology, American Heart Association, and Heart Rhythm Society.
In patients with sinus bradycardia secondary to therapeutic use of digitalis, beta-blockers, or
calcium channel blockers, simple discontinuation of the drug, along with monitored observation,
are often all that is necessary. Occasionally, intravenous atropine and temporary pacing are

Treatment of postinfectious bradycardia usually requires permanent pacing.

In patients with hypothermia who have confirmed sinus bradycardia with a pulse, atropine and
pacing are usually not recommended because of myocardial irritability. Rewarming and
supportive measures are the mainstays of therapy.

Sinus bradycardia may be seen in patients undergoing therapeutic hypothermia. These patients
are likely to develop sinus bradycardia sometime during their course that will require close
monitoring of perfusion status. If they show signs of adequate perfusion, no treatment is
necessary. Treatment of inadequate perfusion would include pressors, atropine, and pacing.
Sleep apnea is usually treated with weight loss, nasal bilevel positive airway pressure (BiPAP)
and, occasionally, surgery.


Drug treatment of sinus bradycardia is usually not indicated for asymptomatic patients. In
symptomatic patients, underlying electrolyte or acid-base disorders or hypoxia should be
corrected. Intravenous atropine may provide temporary improvement in symptomatic patients,
although its use should be balanced by an appreciation of the increase in myocardial oxygen
demand this agent causes.3

Although in the past, isoproterenol was used quite commonly in patients with bradycardia,
further appreciation of its substantial risks has diminished its role. Temporary pacing is
recommended in symptomatic patients who are unresponsive or only temporarily responsive to
atropine, or in whom atropine therapy is contraindicated. Transcutaneous pacing, where
available, is the initial procedure of choice.

These agents are indicated when symptoms of hypoperfusion exist. They are thought to work
centrally by suppressing conduction in the vestibular cerebellar pathways. They may have an
inhibitory effect on the parasympathetic nervous system.

Atropine IV/IM

Used to increase heart rate through vagolytic effects, causing increase in cardiac output.